Symposium
The Hon Frank Walker QC - SFNSW President's Opening Address - Symposium 2009
Here we reproduce SFNSW President Frank Walker's Symposium speech in full. Frank has addressed the areas needing reform within mental health services and administration in NSW. We would encourage members and friends to circulate this as it provides a blueprint for the way ahead.
In these times of global economic meltdown it has become fashionable to refer, ominously, to "the elephant in the room" when we are talking about a massive crisis that is present but ignored by the powers that be. When it comes to the delivery of mental health services in NSW we too have a gigantic pachyderm that the Office of Mental Health refuses to admit exists.
I refer to the shameful state of affairs whereby, of the 700,000 NSW citizens who have a mental illness that seriously interferes with their everyday lives, two thirds or 460,000 will go undiagnosed or untreated and 90% or 630,000 will not access Government Hospitals.
In 2000 and again in 2005, the Fellowship, exercising our advocacy mandate, raised with the NSW Government the issue of the unsatisfactory performance of The NSW Centre for Mental Health. We did this in response to the despair of our membership at the dysfunctional, out of touch, bureaucratically incompetent organisation that the Centre had become only two decades after the Richmond Committee reforms in the mid 1980's.
It is not as if the Centre had no policies. On the contrary, every time politicians or the media raise questions about the systems manifest shortcomings departmental spin doctors' wheel out shiny new policies to allay community outrage and paper over the cracks. In practice, with the exception of the development of the odd pilot program, nothing is done to implement those policies and the system continues to betray our consumers, their carers and mental health professionals.
It is appropriate that three years on we should again mark the Offices report card in respect of the promised reforms that flowed from our 2005 campaign. But first some background on the issues.
David Richmond's inspired, but ultimately unsuccessful, attempt in 1983 to change the culture and policy of NSW health bureaucrats failed because they continued to tenaciously cling to outdated socialist ideology that mental health services should only be delivered through the public health system and then only in accordance with their misguided 18th century view that mental illness was incurable and that tax payers should be inconvenienced only to the extent necessary to protect the community from dangerous delusional patients.
Mental health policy was then administered by Chief Psychiatrists whose work was limited to purely clinical oversight and characterised by their fierce protection of the professional monopoly exercised by psychiatrists over mental health services.
Aside from putting the finishing touches on the closing down the of scandalously administered lunatic asylums forced upon the Department by Royal Commission in the 1960's, David Richmond recommended the implementation of worlds best practice acute care and rehabilitative programs by both our general hospitals and the community health sector. The Richmond implementation team appointed Alec Glen as unit administrator to run the Centre for Mental Health with a charter to administer the reforms. The unit was to be staffed not only with psychiatrists but a wide range of mental health professionals including psychologists, occupational therapists, social workers, psychiatric nurses and administrators.
Shamefully, senior health bureaucrats, antipathetic to the Wran Governments reforms and contemptuous of the democratic process, undermined the Cabinets unanimous proposals for the introduction of rehabilitative services and turned its back on Richmond's recommendations to involve the community health sector in the provision of mental health services by introducing psycho-social and clinical rehabilitation programs. Alec Glen made the fatal mistake of preparing a report which shone a bright light on the elephant and the failure of the Office to implement the reforms. The report was buried, Glen was removed and rule by a psychiatrist reinstated.
While all of the substantial funds recommended by Richmond to be spent on disability services were expended, only a fraction of the mental health funds allocated by the Wran Cabinet were spent and then only on providing extra beds.
So we saw the entrenchment of the discredited policy of restricting the provision of public mental health services to brief, clinically inadequate, treatments in our psyche units with their limited outreach capacity servicing only a fraction of the folk suffering life threatening delusions and then only for part of the acute phase of their psychosis.
In 2000 we lobbied the Government arguing that the system would greatly be improved, firstly if a competent senior administrator was appointed to head up the unit, secondly if the Richmond recommendations that the community health sector be funded to provide psycho-social rehabilitation be implemented and thirdly if the mental health budget was doubled to 13% of the health budget.
Ministers, notably Craig Knowles and Morris Iemma responded very positively to our advocacy as did the Legislative Council Select Committee. Gradually the reactionary advice of the bureaucracy began to be overruled by their political masters and grants were given to community groups to provide advocacy for their members, improve their governance and run a range of pilot schemes providing psycho-social rehabilitative services.
The Centre for Mental Health was yet again restructured in 2006 by amalgamating it with the much larger Office for Drug and Alcohol policy whose administrative head assumed overall responsibility. Most importantly, Morris Iemma declared mental health reform to be his first priority and took action through COAG which poured a billion dollars of new funds into the system indicating this was but a first step which would continue in future budgets until mental illnesses real contribution to the burden of disease was met. About $50 million of those funds were earmarked for the community health projects with the lions share going to the HASI program.
We were naturally elated by these changes but there was a fatal flaw in the reforms. The failed senior bureaucrats were re-employed and remain in charge of policy advice to the Minister. The spin doctors in the Office of Mental Health continued to parrot the slogan that their policies are about "recovery" but their record clearly demonstrated that they had no commitment to that ideal and had no forward plans to expand rehabilitation services beyond the existing pilot programs which assist only a couple of thousand consumers. The lion's share of their budget is still directed at delivering occasional, inadequate care to consumers in the acute phase of psychosis.
The NSW Mental Health Offices approach reminds me of the episode in Yes Minister where the Minister is asked to officiate at a Health Department public relations stunt to publicise the most efficient hospital in Britain only to discovery that it has no patients. The marginal difference is that in NSW, where about 10 % of our population or 700, 000 citizens suffer from a serious mental illness, less than 30.000 manage to get clinical treatment in the 1500 beds serviced in government mental hospitals during acute phases of their psychosis and about 0.3% receive rehabilitation from Health Department funded community health providers.
Imagine the public outrage if 96% of victims of cancer, cardiovascular disease or accidents were not able to access our hospitals and only 0.3% were offered rehabilitation services!
The Schizophrenia Fellowship of NSW has never suggested that centuries of stigmatisation of mental illness and under funding by Governments of both sides of politics can be reversed overnight. The only realistic answer was that provided by Premier Iemma in the past two budgets of gradually building the mental health budget over a decade or two. Sadly, the Health Department has now secretly cut the additional funds promised to mental health by $10 million. Our intelligence is that all of the cuts are to come out of community health services.
What I am attacking is not only the failure of the Office of Mental Health to implement its policies but also its refusal to accept the reality long acknowledged by comparable developed nations that a policy of brief hospitalisation of consumers for periodic adjustments of medication or ECT, barring the odd miracle, offers no hope of recovery and that worlds best practice requires our mainstream health system to be involved in psycho-social and clinical rehabilitation in partnership with community health providers.
A 21st Century Mental Health Plan
Our membership believes that a new 21st century State Mental Health Plan ought to be evolved in consultation with the stakeholders to reform the system over the next decade.. Unless this occurs we will continue to have in NSW a state of affairs where first world standard health professionals are asked to administer a third world standard mental health service.
Our new state health plan should contain the following policy objectives:
1. Accept the reality that mental illness is a critical issue which currently represents almost 14% of the total burden of all disease yet receives only 7% of NSW health funds by phasing in increased funding over the next decade to eliminate the funding inequity.
2. Recognise the need to shift the emphasis in mental health spending to a genuine strategy to achieve recovery featuring early prevention and support for the most vulnerable consumers; particularly the many thousands of homeless living on our streets and the hundreds of thousands who go undiagnosed and untreated.
3. Recognise that rehabilitation is just as important for mental illness as it is for "physical" brain injuries and that consumers have a right to both clinical and psycho-social rehabilitative support services.
4. Accept that international experience has established that the consumer friendly community health services have a major role to play in the delivery of successful clinical and psycho-social rehabilitative services and will substantially relieve the impossible pressures on hospital beds giving the 66% of untreated and undiagnosed mentally ill folk a chance of access to the public health system.
5. Have a coherent strategy to integrate the work of the many service providers focussing on genuine partnerships between consumers, carers, Government, health professionals and community health providers to facilitate the continuous holistic care that is essential if meaningful recovery is to be achieved.
6. Introduce the highly successful Victorian initiatives of early psychosis prevention and intervention centres; linking of acute mental health services to a rapid response outreach teams to treat onsets of psychosis and a 'step up step down" linking of sub-acute community based services with hospital based acute services.
7. Recognise that a large proportion of consumers have co-morbid drug and alcohol dependency and take steps to establish dual diagnosis treatment centres in all Area Health Services.
8. Accept that social exclusion is an outcome of mental illness and support community centre based initiatives that provide socialisation, personal development, living skills training and pre-vocational and vocational training.
9. Recognise that supported employment and a range of housing options are vital components to successful rehabilitation. Because a variety of illnesses are represented when we talk of mental health and the burden of disorder varies greatly, housing and jobs need to be tailored to the consumers needs.
10. Recognise that carers are currently shouldering 90% of the cost of the mental health burden and there needs to be a gradual expansion of existing carer support and respite schemes.
11. Recognise that there needs to be a well funded highly professional education program in our schools, workplaces and the community generally, not only to reduce stigma but to support consumers and their carers and facilitate early intervention that offers the best chance of recovery.
Role of Health Professionals
The Schizophrenia Fellowship is deeply concerned that large numbers of funded hospital beds remain empty because of shortages of mental health professionals to service them. The crisis continues to worsen despite recruitment of overseas trained workers. One of the many reasons for the shortage is the frustrations of Government employed health workers with the outdated thinking and mismanagement of the Department.
A self sufficient Australian training scheme needs to be put in place before the current crisis in our psychiatric units implodes. That scheme should also involve the recruitment of a wider range of health professionals including clinical psychologists, psychologists, general practitioners, mental health nurse practitioners, occupational therapists and social workers. It should also consider credentialing workers with other skills such as educators who have been proved to be effective in private mental hospitals in relieving the recruitment crisis.
The Department needs to publicly acknowledge that periodic tinkering by psychiatric registrars with the medication of less than 30,000 sufferers offers almost no hope of recovery for them and no hope at all to the 66% who go undiagnosed and untreated by the public health system.
The State also has to invest more in mental health competency training for our primary care workforce. It is significant that the Department cannot find staff to service the available beds yet community health providers have been able to recruit large numbers of highly qualified staff who are prepared to accept much lower salaries.
Restructure of the Office of Mental Health
Decades of failure demand a sweeping solution. The Ministry of Health, once a prized portfolio, has become a Bermuda triangle for a great many promising political careers over the past 30 years. Self interest alone requires our Parliamentary leaders to find ways to drain the poison from the health chalice. The policy malaise is at its most evident in mental health which is a basket case crying out for radical reform. Our Fellowship is advocating the following reforms:
1. The creation of a separate Ministry of Mental Health with its own budget. In the past crises in the health system have regularly seen mental health funds raided or cut. That process continues as we speak. Junior Mental Health Ministers have recently performed credibly but their calls for more funds or reforms have been ignored by overworked senior Ministers with all their attention focussed on saving their own political hides as our dysfunctional hospital system, almost daily, produces headlines about scandalous administrative failures.
2. The abolition of the Office of Mental Health and its replacement by a Ministerial Advisory Unit to delivery policy advice to the Minister. The unit need not be as large as the current office but should include more highly qualified health professionals and be led by the Chief Psychiatrist. Hopefully the new policy makers will be selected on the basis that they are genuinely committed to reforming the system. I am not suggesting that the current incumbents be sacked. They should, instead, be reassigned to work at the coal face to sort out the mess they have created.
3. It would be helpful if the portfolio could be given a higher status in the Ministry to reflect the statements by the last two Premiers that mental health was top of their priority list. The Ministry could be made more powerful by adding allied areas of health care such as forensic patients, drug and alcohol and disability services. Aged care, with its high incidence of brain disorders, and Housing, because a majority of our homeless have a mental illness also have potential for building a senior portfolio.
4. There are, of course, plenty of examples of over large or particularly difficult Ministries being successfully split-for example Treasury and Finance or Attorney General and Justice.
5. There should be a special initiative to provide youth with access to mental health services. The ABS 2008 survey indicates that a large proportion of the 2.1 million Australians with a mental illness who could not access mental health services were aged 12 to 25. Given the strong evidence in favour of early intervention there is a powerful case for a youth friendly community based service with a family oriented approach to be established. Again Youth could help build the super ministry.
Conclusion
To conclude I wish to say that after 24 years of service as a NSW politician it galls me that our State, which was regarded internationally as a centre of excellence in the 70's and 80's when it came to propagating leading edge research and treatment of mental health now, after 30 years of backsliding, has to look with envy to Victoria, New Zealand and the United Kingdom as our superiors when it comes to funding best practice mental health care and rehabilitation programs. Our consumers, carers and health professionals deserve far better.
The Hon Frank Walker QC - President
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